Investigating her death, the state Department of Health found that eight other people in mental health crises walked away between January and April. None of those died.

The Health Department fined Holy Spirit $26,000 after concluding the hospital failed to adequately supervise patients who might be suicidal and failed to follow up on patients who “eloped” after going there for mental health-related reasons. The agency’s report became public on Thursday.

East Pennsboro Twp.-based Holy Spirit has made policy changes in response to the department’s findings.

These include continual supervision of emergency room patients who might be suicidal, immediately summoning a specialized crisis worker, and increased training of ER staff.

The department also is requiring Holy Spirit to keep detailed records of such patients.

The 30-year-old Martin committed suicide by rolling under a speeding car on the M. Harvey Taylor Bridge bypass April 17. She died minutes after slipping out of the ER at Holy Spirit, where she had been taken following a suicide attempt.

The department faulted Holy Spirit for failing to keep Martin safe.

According to the Health Department, police were called to Martin’s home in Steelton on the evening of April 17.

Police said they prevented Martin from jumping out of a second-floor window. They said they told Martin she would be committed for mental health evaluation unless she agreed to a voluntary evaluation.

Martin agreed to go voluntarily, and police called an ambulance.

The state’s findings

Shortly after Martin arrived at Holy Spirit at about 9:20 p.m., it was known to emergency room staff that she had tried to jump out a window, had a history of depression and suicide attempts and had self-inflicted injuries on her forearms, according to the Health Department.

Martin also had stated to Holy Spirit staff that she wished she would have been allowed to jump.

View full sizeMonica von DobeneckDawn Martin was killed along this stretch of the Taylor Bridge Bypass.

But hospital staff later noted that Martin was cooperative and “content.” As of 10:45 p.m., she was in an open examination room as staff awaited results of a medical evaluation.

At 11:05 p.m., a nurse noticed she was gone and notified security, which searched for her. At 11:13 p.m., the hospital notified police she was missing, the Health Department stated.

A videotape later showed her walking through the emergency department discharge area at 10:47 p.m. wearing paper scrubs and socks. It showed her leaving through the Emergency Department entrance and disappearing into a wooded area.

She was fatally struck shortly after 11 p.m. after several other vehicles swerved and missed her.

In the past, the hospital typically waited for the results of the medical evaluation before pairing the patient with the crisis-intervention specialist, he said. The purpose was to make sure all medical factors had been taken into account.

Holy Spirit also has changed its policies to ensure that a staff member is immediately assigned to watch patients who arrive because of a mental health crisis.

Schaffner expressed confidence that those steps will speed up the mental health evaluation process, and “markedly reduce” the possibility of a patient walking away from the ER.

The nine patients who “eloped” from the ER left without being immediately noticed, according to the Health Department.

The department stated that Holy Spirit “does not track elopements of the patients who present with mental health-related complaints.”

Schaffner said the hospital follows up on such cases, attempting to contact the patients and sometimes notifying police. He didn’t know if such follow-ups occurred in the cases described by the Health Department.

Schaffner said Holy Spirit “concurs” with the department’s findings and is cooperating.

Holy Spirit has a specialized mental health unit, and Cumberland County residents dealing with mental health crises are taken to the hospital’s emergency room.

Taylor Andrews, a longtime advocate for people with mental illness in Cumberland County, hadn’t yet read the Health Department report.

Upon hearing a description of changes carried out by Holy Spirit, he said, “I’m pleased to hear of the corrective action. ... If it had been in effect, this tragedy might have been averted.”

He said he was surprised to hear of the nine elopements.

Andrews further said it’s challenging for hospitals to deal with people who come to the emergency room for voluntary treatment and then decide to leave.

“They are often fickle about getting help. They can change their mind,” he said. “I don’t know what basis the hospital has to keep them from walking out, other than persuasion.”

Schaffner expressed the belief that if a staff member maintains constant interaction with the patient and the crisis-intervention specialist arrives promptly, they will be able to persuade the patient to stay.

The law prevents people from being restrained for mental health treatment until it’s clear they are a danger to themselves or others.

About 6,000 mental health crisis patients were taken to Holy Spirit Hospital during the 2010-11 fiscal year, and 1,587 were admitted to Holy Spirit or another inpatient mental health unit, said Scott Dugan, a hospital spokesman.

In 2000, Ryan Schorr, who was affected by bipolar disorder, escaped from Holy Spirit and was later shot and killed by police who responded to a disturbance at his home.

At a glance:

The Pennsylvania Department of Health faulted Holy Spirit Hospital for failing to ensure the safety of Dawn Martin, who was taken to the emergency room in April after displaying suicidal behavior.

Martin walked out of the emergency room unnoticed and died after flinging herself into speeding traffic.

The department found that eight other patients who went to the ER because of mental health crises between January and April walked away unnoticed.

The department fined Holy Spirit $26,000 and required it to carry out a plan of correction.

Holy Spirit’s plan is in place. It includes continual monitoring of patients in mental health crisis and faster involvement of a crisis-intervention specialist.

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